Monroeville Municipal Authority Auto-Pay Program

Please fill out the following form, print it out, and send along with a VOIDED CHECK.  You may send this with your next water payment, or bring it to the Monroeville Municipal Authority Office.

AUTHORIZATION AGREEMENT FOR ORIGINATION OF ACH ENTRIES (ACH CREDITS OR DEBITS)

Company Name: Monroeville Municipal Authority

Water Acct. Number:___________________

I (we) hereby authorize Monroeville Municipal Authority, hereinafter called COMPANY,  to initiate automated clearinghouse entries to my (our) CHECKING / SAVINGS account (circle one) indicated below and the depository named below, herein called DEPOSITORY, to credit and/or debit the same to such account.

DEPOSITORY
NAME__________________________________ BRANCH_________________________ 

CITY________________________ STATE_________ ZIP ________________ 

TRANSIT/ABA NO. ___________________ ACCOUNT NO. _________________________ 

This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. 

NAME(S) ___________________________________________________________________

ADDRESS ___________________________________________________________________

_____________________________________________________________________________

E-MAIL ADDRESS (if applicable) ______________________________ 

DATE __________________ SIGNED X ____________________________________ 

SIGNED X ____________________________________

Reminder: Please send VOIDED CHECK with this application.

You may send this with your next water payment, or bring it to the Monroeville Municipal Authority Office, or mail to:

Monroeville Municipal Authority
219 Speelman Lane
Monroeville, PA  15146